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The Silken Tent

May 30, 2015

By Robert Frost

Robert, Kay and Ted in 1948

Frost had been a faithful husband for 47 years but when Elinor died in 1938 the famous poet became fair game. Kay Morrison, the wife of a colleague, seduced him within the year.  Frost, smitten by the contrast between Kay’s public persona – respectable wife, two children – and her passionate sexuality, urged marriage, but she would not leave Ted.  Over the 25 years till Frost’s death the tangle became ever more complicated. This famous sonnet was written when it was fresh.*

The Silken Tent

She is as in a field a silken tent
At midday when the sunny summer breeze
Has dried the dew and all its ropes relent,
So that in guys it gently sways at ease,
And its supporting central cedar pole,
That is its pinnacle to heavenward
And signifies the sureness of the soul,
Seems to owe naught to any single cord,
But strictly held by none, is loosely bound
By countless silken ties of love and thought
To every thing on earth the compass round,
And only by one’s going slightly taut
In the capriciousness of summer air
Is of the slightest bondage made aware.

*Myers J. An Earring for Erring: Robert Frost and Kay Morrison. American Scholar (Spring 1996); 65 (2):219-41. Available here.

Wolvercote community orchard

May 26, 2015

Opposite the Trout at Godstow

Overgrown but still loved and tended.

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The well in the centre with a plaque to Ralph Austen.

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Most trees labelled.

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IMG_20150523_171618364_HDR    IMG_20150523_171107565

Next door the allotment from which the orchard was created, and at the back some beehives.

Ralph Austen was a 17th century nurseryman, cider maker, and early environmentalist from Oxford.

A_Treatise_of_Fruit_Trees_Austen

Take a walk here when you next visit the Trout at Godstow (click here).  Click here for the orchard website.

Jim Thornton

Conflicted HRT “experts”

May 25, 2015

Updated list in HealthWatch

My list of “experts”, who repeatedly publish articles and give talks extolling the benefits of post-menopausal hormone replacement therapy (HRT) without mentioning their associations with the companies who manufacture and market such drugs, has just been published in HealthWatch newsletter 97. Here is a copy. Spring 2015 issue 97 optimized (2)  My article is on page 3. Click here for HealthWatch itself. Click here and here for earlier lists. Click here for the original Cancun Conflicts list, and here for the Hot Flash Havoc list.

The official advice, from both the UK Medicines & Healthcare devices Regulatory Authority (MHRA) and the US Federal Drug Administration (FDA), remains:

Take HRT for symptoms only, in the lowest dose and for the shortest time possible, and never for health promotion.

If you come across any “expert” saying different, check out who’s paying them.

Jim Thornton

For You

April 26, 2015

By Maureen N. McLane

maureen-mclane-448

I’d never heard of Maureen N. McLane – Wikipaedia says she’s Associate Professor of English at New York University – but this love poem, in this week’s New Yorker, hits the spot.

For you

It’s been a long while since I was up before you
but here I am, up before you.

I see you sleeping now that I am up before you.
I see the whole morning before you.

How dare the sun be up before you
when the moon last night promised to hold off the sun just for you!

I hear the church bells ring before you.
Most days it’s true the birds are up before you.

I should make the coffee, as I am up before you.
I might just lie here though before you

wake up. Let me look at you, since I am here before you.
I am so rarely simply quiet before you.

The orange cat who’ll soon wake you is always up before you.
In Morocco or Lamu the muezzin would be up before you.

And yes it’s true most days the sun is up before you—
long before me and a while before you.

Shall I make it a habit, to be up before you?
To see your soft cheek and feel your breath if I am up before you?

Shall I prepare the mise-en-scène for you?
Hold the shot of the sun in my eye just for you?

Go back to sleep my love for you
are only dreaming I am up before you.

Safety of home birth

April 15, 2015

Important, and reassuring, new evidence from the Netherlands

Evaluating the relative safety of home and hospital birth is tricky; most home births are low-risk and many hospital ones high risk, so comparing outcomes for babies born in either place is hopelessly biased. And it’s difficult to adjust for risk status after the event, so until recently most researchers have ended up concluding that home birth might be safe, or might be a bit more dangerous, but they can’t be sure. This has left the field clear for partisans to shout at each other across the barricades.

To answer the question properly we need to identify, before labour starts, low-risk women who plan to deliver at home and low-risk women who plan to deliver in hospital, and compare outcomes by the planned, not the actual, place of birth. Unfortunately such data are rarely recorded.

Until 2011, when the UK Birthplace Study (click here), registered 17,000 women planning to deliver at home, and 20,000 planning to deliver in hospital, recorded their risk status before they went into labour and compared outcomes by planned place of birth. For the low-risk women who had already had a baby, home birth was as safe as hospital. But for low-risk women giving birth for the first time, “there were 9.3 adverse perinatal outcome events per 1000 planned home births compared with 5.3 per 1000 births for births planned in obstetric units, and this finding was statistically significant”. Hence current UK advice that hospital is slightly safer for first births.

However, some Birthplace “adverse perinatal outcomes”, like encephalopathy and meconium aspiration, while undoubtedly serious, are things from which most babies eventually recover, and their diagnosis could also be influenced by knowledge of the intended place of birth. Perinatal death is a harder outcome, but rare. Among low-risk women giving birth for the first time in Birthplace there were only six deaths out of 4,500 deliveries in the planned home birth group and five out of 10,000 in the planned hospital group. These raw numbers favour hospital, but they are hardly conclusive. We need larger numbers, and this month the Dutch have provided them.

Ank-de-Jong

Professor Ank de Jong (above) from the Department of Midwifery Science at the Free University in Amsterdam, and her obstetric colleagues, combined three Dutch registries to do a Birthplace type analysis; namely one based on planned place of birth among women judged at low risk before the onset of labour. The 750,000 women planning home birth dwarf all previous similar studies, so her conclusions matter. The paper is in this month’s BJOG (click here) or for those with access problems Jonge_et_al-2015.

There was no difference in perinatal death between planned home and planned hospital births among low-risk women. The lack of difference applied to both first and later births. For first births the rates were 1.02/1000 for planned home births v. 1.09/1000 for planned hospital births, (adjusted odds ratio 0.99, 95% confidence interval 0.79–1.24).

In summary, and in contrast to the UK Birthplace results, home appears to be safe for first births in Holland. This is important news.

The BJOG editor obviously realised the topic was controversial and commissioned not one, but two commentaries.

frank chervenak

The first (click here) (or Chervenak_et_al-2015) was led by Frank Chervenak (above) a respected New York obstetrician. (Full disclosure Dr Chervenak is a well-known opponent of home birth.  I’ve known him for years, and coincidentally I debated this topic with him at an obstetric conference a few weeks ago. I wasn’t aware of de Jonge at that time!)

Read it for yourself, but in my, perhaps biased, opinion he made five weak points in his commentary, and one good one.

  1. He cited a quite different, much smaller, and much criticised, single centre Dutch study (click here) to suggest that the data on intended place of delivery was inaccurate.
  2. He grumbled about the high rate of missing data on neonatal deaths after one week of age, while ignoring the fact that this was probably random. The fact that some neonatal units did not report any data at all to the national registry is a pity but hardly likely to introduce bias. The authors’ sensitivity analyses did not alter the conclusions.
  3. He suggested that home birth recording of Apgar scores may be inaccurate. This may be correct, but it has no bearing on risk of death. You can misrecord an Apgar, but dead is dead!
  4. NICU admissions were higher among babies of nulliparous women planning to deliver at home, as compared with multiparous women planning to deliver at home, but this is also irrelevant to the question at hand.
  5. Finally he found a Dutch language article in which one of the authors, professor Jan Nijhuis from Maastricht, had apparently recommended that all nulliparous women should deliver in hospital.  I don’t have access, and can’t read Dutch, but surely the fact that Nijhuis was not a reflex supporter of home birth, but happy to stand behind de Jong’s paper strengthens her conclusions!

However, Chervenak made one good point.

  1. Even if home birth is safe for low risk women in the Netherlands, a small country with well-trained midwives, and well-regulated systems in place, it may not be safe in the US where home births are often supervised by untrained self-styled experts.

He is surely right about that! Although whether this means US obstetricians should campaign for better midwifery support for home birth, or for everyone to deliver in hospital, is another matter!

Marian Knight

The other comment piece (click here) was by Marion Knight (above), one of the Birthplace researchers. She agreed that the Dutch data were reassuring, but worried about the same missing deaths which had concerned Chervenak; although they were probably random and probably wouldn’t have altered the conclusions, there were rather a lot of them.  Since Birthplace had more complete data, she suggested it may more accurately reflect the relative safety for low-risk women giving birth for the first time in the UK.

I agree with Dr Knight. For low-risk women in their first pregnancy I will continue to advise that in the UK hospital is probably safer. But if they wish to go ahead and deliver at home, these new Dutch data suggest there’s no need to make a fuss.

Of course none of this applies to women with significant risk factors (click here); they would be much safer in hospital.

Jim Thornton

Jim’s tweet

April 11, 2015

Home birth after three Caesareans

A few days ago I tweeted:

Hvba3c

The link (click here) was to a mother’s post about her successful home vaginal birth after three Caesareans (HVBA3C). The recipients were James Titcombe whose son Joshua died in Morecambe Bay NHS Trust, led the campaign for a public enquiry, and was vindicated by the Kirkup Report (click here). Amy Tuteur is a retired US obstetrician and blogger who campaigns against, as she sees it, anti-science attitudes in pregnancy and childcare. Her views on anti-vax parents are mainstream, but her rejection of the idea that natural childbirth is a good in itself, and specifically her uncompromising hostility to home birth, (click here for her blog) get some people’s backs up.

Sheena Byrom, a retired UK midwife, and author of many books about natural childbirth tweeted; “I am so shocked that you engage this way on Twitter Jim. Is it a game?”

HVBA3Cc

Byrom had crossed swords with Tuteur before – she regards her as an internet troll who enjoys picking fights with supporters of natural childbirth – and felt it inappropriate to copy a mother’s personal, albeit public, blog about her happy and successful birth to such a person. James Titcombe defended me, and soon found himself embroiled in the row. Others accused me of being unprofessional, and likened Titcombe, Tuteur and Thornton to Macbeth’s three witches.

Before long Tuteur had lived up to Byrom’s expectations by fanning the flames as hard as she could (click here and here). Tuteur has a pungent writing style – I’m sure neutrals find her a good read, and you wouldn’t have to look hard to find health professionals who agree with her – but she does go for the woman not the ball!

I’m afraid I kept my head down – accusations of unprofessionalism, especially when copied to the RCOG make me nervous; I’m still in clinical practice and have had run-ins with them before – and when something goes viral it is difficult to avoid digging a bigger hole. But the argument and retweeting have gone on and on. So here are my thoughts.

Background

My initial tweet was not out of the blue; I don’t search the internet for risky birth stories to show Amy Tuteur. It followed an invitation to comment on another mother’s blog (click here) describing her successful vaginal birth after two Caesareans (VBA2C).

VBA2Ca

Like the anonymous obstetrician criticised in that blog, I strongly discourage VBA2C, but the references cited, and RCOG guidance suggest I may be wrong, and I’ve also reluctantly looked after a couple of cases myself, which I admit turned out OK. So I said what I usually say, “discourage but support”.

Soon I was invited to comment on another post. The one whose link I later forwarded, namely the home vaginal birth after three Caesareans (HVBA3C).

VBA2Cb

Calling HVBA3C a “first world problem” was flippant, but I still think that home birth in that situation was foolhardy.  The risk of uterine rupture is at least 1 in 200, perhaps higher without continuous fetal heart rate monitoring, or if the woman is determined to push on in the presence of slow progress, and the baby will certainly die if rupture occurs at home. It’s not as dangerous as Russian roulette, but considerably more so than not buckling yourself or your baby into your car seats. So rightly or wrongly, I forwarded the link to Titcombe and Tuteur.

Why did it cause such trouble?

There is a battle here, and some truth on both sides.  Modern obstetrics, the stuff I do every day, is obsessed by reducing risk. Caesareans for breeches, antibiotics for positive group B strep swabs, and heparin for anyone with a risk factor for thromboembolism are all unnecessary most of the time, but heaven preserve the doctor who skips them if a bad outcome occurs. We drill our staff again and again about how to interpret fetal heart rate abnormalities, and even then we don’t trust them completely; every few hours we insist on a “fresh eyes” review.  We’re trying to squeeze the last drop of risk out of childbirth, and that’s not a bad thing.  Parents want a healthy baby. They don’t want to hear:

“We’re sorry things turned out bad, but your complication is rare. To prevent your baby’s death we’d have to monitor hundreds of babies, do hundreds of Caesareans, or give thousands of women antibiotics.”

They would rightly reply:

“Why not? I’d have a Caesarean for a 1 in 200 risk, or take penicillin for a 1 in 1000 one.”

But our obsession with safety has a cost. It causes anxiety. Fetal monitoring does lead to unnecessary Caesareans. People popping in and out of rooms to review progress, give antibiotics and check heart beats, stops women relaxing and may actually slow labour.

And supporters of natural childbirth are right. Hospitals are not perfect. Too many women still labour on their backs. Doctors make stupid decisions. And even if we were perfect, it might still sometimes be better to take a bit of risk to allow nature to take its course. Homebirth might be less risky than we believe.

The Birthplace Study (click here), undoubtedly the best quality research into the question, showed that for low risk multiparous women, looked after by properly trained midwives in the UK, home is as safe as hospital.  Even for first pregnancies the additional risk is quite small, such that some women might rationally decide to take it.  I’m not an opponent of home birth.

But, there surely is a line we should not support, and birth at home after Caesarean is on the wrong side of it. We can’t stop parents making bad decisions, but professional supporters of home birth unavoidably tread that line. Read the HVBA3C story again (click here).  Did the midwife who told the mother she could have “a natural birth no matter how many sections I’d had” cross it?

Last year, the Kirkup report on Morecambe Bay concluded:

“Midwifery care became strongly influenced by a small number of dominant midwives whose ‘over-zealous’ pursuit of natural childbirth ‘at any cost’ led at times to unsafe care.”

When I read that at the time, my reaction was: Surely not. I’ve never met or, until Kirkup, even heard of a midwife acting like that. Lots of other things went wrong in Morecambe Bay, but this sounds like someone is dumping on the midwives.

And I’ve read Sheena Byrom’s writings, and I know people who know her well. She is not “pursuing natural childbirth at any cost”. At the risk of putting words in her mouth, she would say that once a woman has decided to have a home birth whatever the risk, typically after being told ad nauseam by people like me and Amy Tuteur that she is risking her own and her baby’s life, there is nothing to be gained and everything to be lost by banging on about the dangers again. We cannot arrest women. If they fall out with their home birth midwife, they don’t always return meekly to hospital. They sometime deliver at home with no assistance at all. That is much less likely to end well. I get all that.

So let me be plain. Amy Tuteur is wrong. Sheena Byrom and her colleagues are also trying to make birth safer. I am sorry my tweet led to their motives being impugned yet again.

But …

When one of the retweeters wrote about the HVBA3C blog “What an amazing story thanks for sharing let’s hope it empowers more women”, I did have sympathy with Amy Tuteur’s response:

“Let’s hope it doesn’t kill anyone”.

hvba3ce

Midwifery and obstetrics are tough jobs. We tread narrow lines.

Jim Thornton

Late published trials

April 3, 2015

Public sector worst offenders

The pharmaceutical industry is often accused of failing to publish their clinical trials; a paper in this week’s New England Journal of Medicine confirms they are sometimes guilty, but far from the worst offenders. Click here for full text, or for those with access problems, rct results reporting.

Among 32,656 trials, registered at ClinicalTrials.gov, and completed or closed by August 2012, only 13% had reported within one year, and 40% by four.  Commercially funded trials were significantly more timely than those funded by government, academia or charities. Here’s the graph.

trial reporting graph

The researchers also checked if they had a good reason for delay. Nearly half of industry trials (44%) did, compared with only 6% of NIH funded ones and 9% funded by other sources. Overall industry reported 80% of trials on time, or had an acceptable reason for delay, as compared with 50% NIH trials, and 45% for those funded by others.

Even these results are probably biased in favour of the public sector. Industry must register its trials to use the results for licensing.  Trials funded from other sources, often delay registration till publication; check submission and registration dates if you don’t believe me.

Click herehere, here or here for a few egregious examples of late registration or other registry cheating in public sector trials.

Time to stop beating up pharma?

Jim Thornton

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